Identifying systems factors contributing to adverse events in maternal care using incident reports

The maternal mortality rate in the US increased significantly from 20.1 deaths per 100,000 live births in 2019 to 32.9 in 2021. Black women have a higher rate of mortality and also experience higher rates of severe maternal morbidity, which are life-threating maternal health complications. However, maternal mortality and SMM are preventable with timely and responsive care, suggesting opportunities to intervene at the point of care. To examine processes contributing to adverse maternal outcomes and racial/ethnic disparities in these outcomes, we analyzed 550 incident report (IRs) collected in the maternity units of a large academic hospital in 2019 and 2020. IRs were disaggregated by race/ethnicity and the IR narratives were coded using the systems factors from the SEIPS 2.0 model. Tasks (40%) and organization (30%) were most frequently reported SEIPS 2.0 categories. The majority of these incidents were the result of omissions (15%), staffing (9%), teamwork and coordination (7%), specimen labeling errors (7%), and hospital protocols (6%). These findings from this analysis can improve system safety and support the development of targeted efforts to improve health equity for women and birthing of people of color.